Healthcare Provider Details

I. General information

NPI: 1295760254
Provider Name (Legal Business Name): SALLY ELAINE RYDEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 W NEWBERRY RD
GAINESVILLE FL
32605-4309
US

IV. Provider business mailing address

PO BOX 147050 PMB 509
GAINESVILLE FL
32614-7050
US

V. Phone/Fax

Practice location:
  • Phone: 352-333-3495
  • Fax: 352-333-4284
Mailing address:
  • Phone: 352-375-0166
  • Fax: 352-375-1677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME29117
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: